METROPOLITAN POLICE PROFESSIONALISM HQ Deputy Assistant Commissioner Mr Graeme Irvine New Scotland Yard Area Coroner for East London; Walthamstow Coroner's Court Victoria Embankment Queens Road, London Walthamstow, SWIA 2JL E17 8QP Emaili Tel: or 101 Your Ref: Our ref: Date: 30th December 2020 0a tl 17e am the Deputy Assistant Commissioner for Professionalism within the Metropolitan Police Service (MPS) and am responding to your Regulation 28 Report to Prevent Future Deaths dated 12th November 2020 to the Commissioner of Police of the Metropolis. This followed the conclusion of the Inquest into the death of Ms Imane Bouasbia on 3rd January 2020 at Newbury Park Station, London. The Inquest concluded on 22nd September 2020. You raise three matters Of concern: (1) The failure of officer 1 to effectively communicate to officer 2, either verbally or in the CRIS handover, that Ms Bouasbia had expressed the view that she wished to end her own life following the attack she sustained on 1st January 2020. (2) The failure of officer 2 to complete a risk assessment of Ms Bouasbia regarding thoughts of self-harm or suicide_ (3) The police reaction to Ms Bouasbia's Whatsapp text message at of 3rd January 2020 indicating suicidal thoughts was limited to a non-expedited instruction on a CAD action: The only response to Ms Bouasbia was a further Whatsapp text message rather than a telephone call_ MPS response to matters of concern: (1) The failure of officer 1 to effectively communicate to officer 2, either verbally or in the CRIS handover, that Ms Bouasbia had expressed the view that she wished to end her own life following the attack she sustained on 1st January 2020 _

Ms Bouasbia referred to having suicidal thoughts in her initial telephone call to police and these comments were recorded on the Computer Aided Despatch (CAD) report: Officer 1 , who responded to the CAD, was made aware of those comments before she met and spoke with Ms Bouasbia. However; during their conversation officer did not explore this any further as on speaking with Ms Bouasbia the officer was satisfied that those thoughts were no longer present and did not make specific reference to them when completing the report on the Crime Reporting Investigation System (CRIS): However;, officer did provide the CAD reference number in the CRIS report: Unfortunately, the sexual offences investigation team (SOIT) officer (officer 2) did not review the CAD report: The MPS has a policy in place to address this area of concern; however, it would appear that the policy was not adhered to at the time: The MPS General Investigation Initial Investigation Frontline states; Officers are to ensure the safeguarding of any person involved in the investigation by assessing all victimslwitnesses/suspects/persons in line with the Vulnerability Assessment Framework (VAFY. If deemed vulnerable, follow the policing response as per the appropriate toolkit for adults and children. Complete Missing Persons & Related Linked Indices report (MERLIN) and flag appropriately on CRIS" _ The comments made by Ms Bouasbia when she initially reported her allegation to police, should have identified her as "vulnerable" and a MERLIN report should have been completed and signposted on the CRIS report: While it is acknowledged that officer did not complete the MERLIN report; the SOIT officer could have still identified Ms Bouasbia's vulnerability from the CAD report and by ensuring that all police indices were checked prior to contacting Ms Bouasbia: The SOIT officer should have completed this as part of the full risk assessment at the outset of the investigation and prior to making first contact with Ms Bouasbia The MPS has introduced a THRIVE+ vulnerability assessment; which is currently being trialled and is anticipated to be rolled out across the organisation in April 2021. It is a set of principles and a framework to assess the type of policing response or investigation required for particular set of circumstances: THRIVE covers: Threat Harm Risk Investigation Vulnerability Engagement Prevention/Intervention The framework is a tool that aligns to_ and enhances, the National Decision Model and includes the assessment and ongoing review of risk during investigations_ It also provides common language around risk to improve information sharing and decision-making: This assessment tool will ensure officers consider and clearly document vulnerability on CRIS report; enabling a victim's vulnerability to be reviewed throughout the investigation: The THRIVE+ risk assessment covers suicidal thoughts and vulnerability The CAD operator receiving the initial call would complete this assessment and determine what the response grading of the call should for example, if the caller is considered to be extremely vulnerable or suicidal then the CAD operator would endeavour to stay on the call until police officers arrive. To immediately address the lessons learned prior to the full introduction of THRIVE+ on 18th December 2020 an Operational Notice was published on the MPS internal website informing all staff, including SOIT officers , that must review all police indices, including the CAD, prior to contact with the victim. identified vulnerabilities must be communicated to the investigating officer or their supervisor and noted on the CRIS report This will also be addressed in future Continuous Professional Development days for all officers, commencing in February 2021 for SOIT officers_ Policy being every be, they Any

(2) The failure of officer 2 to complete a risk assessment of Ms Bouasbia regarding thoughts of self-harm or suicide. The MPS Rape and Serious Sexual Assault Policy Toolkit _ Secondary Investigation, provides details of the SOIT officer's role and responsibilities. This includes details regarding the completion of a risk assessment with an additional risk assessment if the case is related to domestic abuse. The SOIT officer on this occasion completed a partial risk assessment and did not specifically cover vulnerability or record this on the CRIS report: A SOIT officer completes four-week training course to become qualified in the role. The course covers risk, but does not go into the detail around what documents should be reviewed either before speaking to the victim or whilst the investigation is ongoing_ The MPS has introduced newly enhanced SOIT risk assessment that specifically covers suicide, cultural complexities and concerns around honour-based violence It also mandates that the SOIT officer review all police indices including the CAD_ The new risk assessment is mandatory for all SOIT officers to complete before speaking to complainant and must be recorded on the CRIS report and brought to the attention of a supervisor if there is anything of concern: The CAD report was restricted as per MPS instructions that state; "A CAD for Rape or sexual offences should be restricted where the victim could be identified from the content of the incident" This would relate to most allegations of rape or sexual offences unless the caller refuses to provide their name or address details, which is rare Other officers wishing to review a restricted CAD would be required to contact MetCC or their local Operations Room to gain access. It would appear that the SOIT officer was not aware of this process and therefore this is now covered in the new SOIT risk assessment. (3) The police reaction to Ms Bouasbia's WhatsApp text message at of 3rd January 2020 indicating suicidal thoughts was limited to a non-expedited instruction on a CAD action: The only response to Ms Bouasbia was a further WhatsApp text message rather than a telephone call: The SOIT officer made the decision to return Ms Bouasbia's message via WhatsApp as Ms Bouasbia had been WhatsApp as a method of contact between them: SOIT officers will confirm with the victim the method of contact they would prefer when communicating during an investigation The SOIT officer is led by the victim's preference of contact: The Victim's Code also deems these methods as acceptable for communicating with the victim. However on this occasion, other methods of communication would have been preferable and had the SOIT officer brought this to the attention of the investigating officer or the supervisor, advice or guidance could have been provided on a better method of contacting Ms Bouasbia. In the SOIT officer's WhatsApp text message to Ms Bouasbia, she suggested that she would send officers to Ms Bouasbia's home address to check on her welfare. Ms Bouasbia was not in agreement with this, however, the SOIT officer decided to send request for officers to attend Ms Bouasbia's address to check on her welfare_ Unfortunately, the type of message the SOIT officer sent attaches a response that requires an officer to be at the location within 48 hours. If the officer had contacted the MPS Control Rooms or their local Operations Room direct, she could have explained the circumstances better and asked for a quicker check to be conducted. As a result, the MPS did not allocate this call until some hours later despite acknowledging the CAD message within 29 seconds of its creation: very using

Upon reflection, the SOIT officer accepts that she should have contacted Ms Bouasbia by telephone to speak directly with her. On 21st December 2020, the MPS addressed this by e- mailing all SOIT officers and Public Protection Department managers with the instruction that SOIT and investigating officers must inform a supervising officer if they receive any contact from a victim that causes them concern: A course of action must be agreed and documented on the CRIS report or CAD message and immediate contact made with the victim by telephone_ In addition, SOIT officers must ensure their work mobile telephone recorded answer message provides alternative contact numbers should the SOIT officer be off or uncontactable and the caller needs assistance_ From 2021, further Continuous Professional Development events for SOIT officers will include suicide awareness and a contribution from Hostage and Crisis negotiator regarding how to more effectively engage with a person in a mental health crisis. In conclusion The MPS regrets that officers did not take appropriate action to identify Ms Bouasbia's mental health vulnerabilities and did not respond in an appropriate timely or effective manner to Ms Bouasbia's WhatsApp message of, 3rd January 2020. The two officers involved have engaged in reflective practice with their respective supervisors to ensure that the learning from this tragic event is reflected upon: hope that this response and action addresses the matters of concern you have raised. Please do not hesitate to contact me should you have any further queries.